M. P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION, PLOT NO.76, ARERA HILLS, BHOPAL FIRST APPEAL NO.908 OF 2017 (Arising out of order dated 09.05.2017 passed in Case.No.725/2015 by District Commission, Indore No.2)

JAYANT, R/O NEW 165, PU.123, HUKUMCHAND COLONY, PANCHKUIYA ROAD, INDORE, DISTT. INDORE. … APPELLANT.

Versus

1. UNITED INDIA INSURANCE COMPANY LIMITED, 24, VEETES ROAD, CHENNAI

2. UNITED INDIA INSURANCE COMPANY LIMITED, THROUGH DIVISIONAL MANAGER, INDORE VIKAS PRADHIKARAN, 5^TH FLOOR, BLOCK 3, RACE COURSE ROAD, INDORE. .… RESPONDENT.

BEFORE :

HON’BLE JUSTICE SMT.SUNITA YADAV, PRESIDENT HON’BLE DR. (MRS) MONIKA MALIK, MEMBER COUNSEL FOR PARTIES :

Ms.Mona Paliwal, learned counsel for the appellant.

Shri Ravindra Tiwari, learned counsel for respondents.

O R D E R (Passed on .12.2025)

The following order of the Commission was delivered by Dr.(Mrs) Monika Malik, Member :

This is an appeal by the complainant / appellant directed against the order dated 09.05.2017 passed by the District Consumer Disputes Redressal Commission, Indore No.2 (for short ‘District Commission’) in complaint case no.725/2015, whereby the District Commission has dismissed the complaint filed by him.

2. Briefly put, facts of the case as narrated by the complainant / appellant are that he alongwith his family members was insured via mediclaim policy from the opposite parties / respondents – United India Insurance Company Limited (hereinafter referred to ‘Insurance Company’) for a period w.e.f. 27.01.2015 to 26.01.2016. Previous policy was effective from 28.12.2014 to 27.12.2015. The complainant alleged that he suffered from swine flu and was therefore, admitted in the hospital for treatment regarding the same on 18.02.2015. He was discharged on 21.02.2015 and when claim regarding treatment seeking amount of Rs.9,856/- was lodged by him with the Insurance Company, the same was denied. He therefore, alleging deficiency in service against the Insurance Company, filed complaint before the District Commission.

3. The Insurance Company resisted the complaint on the ground that the claim is not payable on account of condition no.4.2 of the policy terms and conditions.

4. Heard. Perused the record.

5. Learned counsel for the complainant / appellant argued that condition nos.4.2 and 4.3, on the basis of which the District Commission has dismissed the complaint are not applicable in the instant matter. The policy year in which the claim was sought by the complainant / appellant was the 2^nd year in continuation with the Insurance Company. She therefore prayed that the impugned order be set aside.

6. Learned counsel for Insurance Company argued that the complainant / appellant was not insured in the previous policy year with the Insurance Company. Also, there was gap of 21 days in obtaining current insurance policy. Therefore the District Commission has rightly held the claim as not payable. He prayed that the appeal be dismissed.

7. Condition nos.4.2 and 4.3 which is relevant to decide the matter read thus :

“4.2 Any disease other than those stated in clause

4.3 below, contracted by the Insured person during the first 30 days from the commencement date of the policy. The exclusion shall not however, apply in case of the Insured person having been covered for a continuous period of preceding 12 months without any break.

4.3 Unless the Insured has 24 months of continuous coverage, the expenses on treatment of diseases such as Cataract, Benign Prostatic Hyperthrophy, Hysterectomy for Menorrhagia, or Fibromyoma, Hernia, Hydrocele, Congenital internal disease, Fistula in anus, piles, Sinusitis and related disorders, Gall Bladder Stone removal, Gout & Rheumatism, Calculus Diseases are not payable. Internal Congenital Disease means anomaly which is not visible and accessible parts of the body.”

8. The policy documents are also available on record. Previous insurance period is mentioned as 28.12.2014 to 27.12.2015, whereas the current policy was effective from 27.01.2015 to 26.01.2016. Clear